The salami approach is one of the most useful lessons I learned somewhere along the way in my life. If you try to eat, or even imagine eating, a whole slab of salami all at once, it borders on disgusting. However, if you cut the salami into small slices, all of a sudden it looks good! Edible! So it is with the Hospice Item Set (HIS).

I have been giving a lot of thought to the HIS since my last blog post about it two months ago (here). For the past few weeks I have been working with quality guru and favorite colleague Melanie Merriman, Ph.D. on a new manual entitled The Hospice Item Set: A Step-by-Step Guide to Implementation. Although it will not be ready for primetime for another month or so, we wanted to share some of our thinking to date as well as the salami approach we are taking.

We have taken the hunk of salami, in this case the HIS requirements, and divided them into five main chunks, or, more accurately, functions. Each of these main functions is then sliced into specific tasks and responsibilities. The main functions are collecting, abstracting, reviewing, converting and submitting. Here is a flow chart depicting these functions.

1. Collecting the Data

First, the data elements needed to complete the HIS Form must be collected in the patient's record(s). There are administrative data, most of which will be collected during the referral and intake, and clinical data which will be collected and documented after the patient is admitted.

2. Abstracting the Data

The next function is abstracting the data. This entails culling the required data elements from the patient's record to complete the Hospice Item Set - Admission and Hospice Item Set - Discharge forms. Each HIS form constitutes an HIS Record for the patient, so each patient will have two HIS records - an Admission Record and a Discharge Record. Each record must include signature(s) attesting to the accuracy of the abstraction.

3. Reviewing the HIS Record

When the abstraction is finished, each HIS record must be reviewed to assure it is complete, that all required data elements are present. Another attestation must be signed within required timeframes confirming that the record is complete.

4. Converting the Record to an .XML File

Before HIS records can be submitted, each one must be converted to an .XML file format using software designed to do the conversion. Hospices will need to figure out how this will happen if it is not something provided by their electronic medical record vendors (if they have one). CMS will provide software (HART) for the conversion, as will other vendors, or hospices may develop their own software for this purpose.

5. Submitting the HIS Record(s)

The XML files can then be loaded into the CMS's Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. Training and more details regarding how this will work will be provided by CMS in early May.

So voila the "salamified" HIS process. It feels more manageable but it is still very complicated. As we approach each function, here are some of the questions we are grappling with:

How will required time frame requirements be met?

How much will software vendors do / not do?

What questions do hospices need to ask their software vendors regarding each function?

What about hospices that do not have electronic medical records (yes, they certainly exist)?

What policies and procedures are needed for each function?

Who is going to perform each function, what do they need to know and how/where are they going to learn it?

Who is going to make sure each function is completed within required timeframes?

Lots to think about. One thing we are not spending much time on in the manual is an in-depth review of the actual quality measures. Along with the salami approach, another important lesson to live by is not reinventing the wheel. CMS has done an excellent job with its HIS manual and trainings (see additional resources below) going into detail (sometimes excruciating!) regarding the measures so it makes no sense for us to repeat that. Our goal, instead, is to focus on implementation and how to operationalize, as efficiently and cost-effectively as possible, the HIS requirements.

We would welcome your thoughts, comments, and ideas to help us make this manual as helpful as possible for your hospice. Also, if you are interested in being notified when the manual is available and to receive an order form, please send an email to info@weatherbeeresources.com with "Interested in new HIS manual" in the subject line.